Breast cancer is the most commonly diagnosed cancer among Canadian women, with 1 in 9 expected to develop breast cancer in their lifetime.1 Despite the high numbers of diagnoses, the breast cancer mortality rate in Canada is the lowest it has been since 1950.2 This suggests a growing number of breast cancer survivors in Canada and highlights the importance of “life after cancer” and the need to provide supportive services to enhance health-related quality of life (HRQL).
Breast cancer and its extensive treatments can take a significant toll on physical and emotional health and well-being and overall HRQL.3 Recent research highlights exercise as an important tool in the recuperative process for breast cancer patients. Randomized controlled trial and non–randomized controlled trial exercise interventions have shown that exercise can improve physical function, cardiovascular fitness, muscular strength, body composition, levels of fatigue, depression, and overall HRQL.4–9 In addition, exercise can reduce recurrence and mortality rates for breast cancer survivors.10–12 Despite the potential benefits, most cancer survivors experience significant declines in exercise levels after diagnosis, particularly while undergoing treatment.13 There are many reasons for declines in usual activity levels, including symptoms, adverse effects and time constraints due to treatment, confusion regarding the safety of returning to exercise, and a lack of access to individual recommendations or cancer-specific exercise programs. One viable solution to the barriers of misinformation and lack of access is to develop community-based programs specifically for breast cancer survivors. These programs should be evidence based, include education, and promote safe and beneficial exercise in breast cancer survivors.14,15
Recent studies have described the positive effects of community exercise programs on physical, psychosocial, and HRQL outcomes for cancer survivors,16–18 and specifically breast cancer survivors who have completed treatment.19 Only 1 study of a community-based exercise program has included cancer survivors currently undergoing treatment,20 and to our knowledge, there are no previous studies that have evaluated a community-based exercise program specific to breast cancer survivors who were undergoing treatment at the time of the program. Although participants of community exercise programs who are concurrently undergoing chemotherapy and radiation treatment may not experience the same improvements in physical functioning and psychosocial and HRQL outcomes seen in programs that take place later in the cancer trajectory, these programs may have the power to alleviate the usual declines and negative sequelae experienced during treatment.4 Exercise programs delivered during treatment may also be able to capitalize on the “teachable moment” following a cancer diagnosis in which women may be more amenable to making significant health behavior changes,21,22 as well as provide a forum of support during this difficult time along the cancer journey.23
The “Breast cancer patients Engaging in Activity while Undergoing Treatment” (BEAUTY) program is a 12-week exercise program with an optional 12-week maintenance component, offered at no cost to breast cancer survivors. This ongoing community program operates within the Health and Wellness Lab at the University of Calgary, in Alberta, Canada, with funding secured through 2016.24 The goals of BEAUTY are to (1) use exercise and education to restore and maintain the physical well-being of women living with breast cancer while on treatment, (2) increase awareness of the importance of healthy lifestyle behaviors, and (3) provide practical tools and a variety of resources to assist women to actively take charge of their health, fitness, and well-being. BEAUTY participants receive individualized fitness assessments at baseline, 12 weeks, and 24 weeks; personalized exercise plans; twice-weekly group-based exercise classes; and biweekly education classes. The purpose of this article was to evaluate the feasibility of the initial 12 weeks of the BEAUTY program based on (1) the effectiveness of the program in maintaining physical and psychosocial outcomes and (2) the adherence to group glasses, safety, and participant enjoyment of the program.
Participants and Setting
All participants were diagnosed with breast cancer and were being treated at the Tom Baker Cancer Centre in Calgary, Alberta. The current study includes participants enrolled in the BEAUTY program between August 2011 and July 2013. Participants were referred to the program through a number of sources, including via healthcare professionals in the breast tumor group at the Tom Baker Cancer Centre, self-referral to the program through print advertisements (eg, brochures, posters) or educational information sessions at the Cancer Centre, and through program information that was sent to local cancer support groups and nonprofit organizations.
Women older than 18 years and undergoing treatment for breast cancer, or within 3 months of completing treatment (chemotherapy or radiation or combination of both) were eligible for this program. This 3-month criterion was chosen because within 3 months of treatment, participants continue to experience acute and short-term effects that dissipate over time and are often different issues than the common long-term adverse effects. To be included in the program, women also had to be able to attend the program assessments at the University of Calgary and be able to speak and read English. Prior to enrollment, eligible participants had to pass the PAR-Q+ (Physical Activity Readiness Questionnaire for Everyone) to ensure safety for exercise and/or obtain medical clearance for exercise from their physician (PARmed-X).25 By reading and signing an informed consent document, participants were aware of any and all risks associated with participation in the program and also had the option to consent to have their information used for research purposes.
Procedures and Program
Over a 12-week period, participants were given an individualized resistance, aerobic, and flexibility training program based on their health history and baseline fitness testing, designed by a Canadian Society of Exercise Physiology–certified exercise physiologist (CEP). The exercise plan included 2 days per week of aerobic exercise, 1 day per week of resistance exercise, and stretches or flexibility exercises 5 to 7 days per week. Aerobic sessions were prescribed at intensity between 40% and 60% of their heart rate reserve or at a rating of perceived exertion of 1 to 3. Aerobic prescriptions were adjusted to individual fitness level based on the CEP’s assessment. Participants were instructed to wear a heart rate monitor during aerobic exercise sessions or take a 10-second count of their pulse at the wrist or neck periodically during the workout. Aerobic duration was prescribed as 20 to 60 minutes per session, dependent on fitness level and in-session fatigue and energy checks. Resistance training was prescribed as 2 to 3 sets of 8 to 12 reps of 10 to 12 exercises, using light resistance.
The CEP provided the participant with 3 levels of difficulty (easiest, medium, harder) for their program, tailored to their energy or fatigue level on any given day. Participants had the option of group-based exercise classes and home-based workouts. Participants were encouraged to attend group-based exercise classes at least once per week. These classes were offered 2 days per week at the Thrive Centre (a free exercise facility for cancer survivors at the University of Calgary). Exercise classes were 60 minutes in duration and included aerobic exercise on cardio machines (ie, elliptical, treadmill, rower, and bike) and low-resistance muscle strength and endurance movements (ie, circuit training). The use of inexpensive exercise equipment, such as bands, dumbbells, steps, and balls, ensured that exercises were easy to replicate at home for minimal cost. Prior to the start and at the conclusion of each group exercise session, participants reported their perceived rating of fatigue and energy. A resource package was provided to each participant with pictures and descriptions of all exercises to facilitate the home-based option. Participants were also asked to track their weekly exercise using a fitness log, to enhance accountability for the home-based exercise program in particular.
BEAUTY also included biweekly educational sessions. Educations sessions were held immediately following one of the group-based exercise classes in the Thrive Centre. The educational sessions were designed to build the necessary self-regulatory skills for the participants to become independent, successful habitual exercisers upon program completion. These sessions provided knowledge on topics including goal setting, principles of exercise, physical and psychosocial benefits of exercise, nutrition, sleep and fatigue, stress management, social support, and brain fog.
Resting heart rate, blood pressure, height, weight, waist and hip circumference, and 5-site skin fold to estimate percent body fat were measured at baseline and 12 weeks by a CEP. The CEP also measured musculoskeletal strength and endurance using grip strength (upper body) and the 7-level sit-up test (abdominal/core), as well as hamstring flexibility using the sit-and-reach test. At both time points, aerobic fitness was measured using a submaximal treadmill test, with an end point of 85% age-predicted maximum heart rate, following a modified Balke and Ware26 protocol. Maximal oxygen consumption (VO2max) was estimated using a standardized equation.27 The CEP was trained in breast cancer–specific modifications for each measure, and testing procedures followed components of the Canadian Physical Activity, Fitness and Lifestyle Approach manual28 and other validated protocols.27
Self-report measures were used to assess HRQL, cognitive function, fatigue, and depressive symptoms at baseline and 12 weeks. Health-related quality of life, cognitive function, and fatigue were assessed using measures from the Functional Assessment of Chronic Illness Therapy (FACIT) Measurement System,29 a series of questionnaires that measure HRQL for people with chronic illnesses. Health-related quality of life was measured using the Functional Assessment of Cancer Therapy (FACT-B) for patients with breast cancer,30 cognitive function using the FACT-Cog,31 and fatigue using the FACIT-Fatigue subscale.32 Functional Assessment of Cancer Therapy scales have been previously tested for reliability and validity across different types of cancer, including breast cancer.33–35 The FACT-B (version 4) is a 37-item self-report measure yielding a total score ranging from 0 to 144. This questionnaire consists of subscales evaluating physical, social, emotional, and functional well-being and a breast cancer symptoms–specific subscale, with higher scores in each subscale indicating better HRQL. The FACT-Cog questionnaire consists of 4 subscales, with higher scores on each subscale indicating better cognitive processes. The FACIT-Fatigue subscale (version 4) is a 13-item self-report measure that yields scores ranging from 0 to 52, with higher scores indicating less fatigue. Depressive symptoms were measured using the Center for Epidemiologic Studies Depression Scale (CES-D), a 20-item scale with scores ranging from 0 to 60, with higher scores indicating more depressive symptoms.36 The CES-D has been found to be reliable and valid in a cancer population.37
ATTENDANCE, PARTICIPANT ENJOYMENT AND SAFETY
Attendance at group exercise and education sessions was tracked using a log-in sheet and recorded by program staff. Participants completed a 12-week evaluation consisting of 8 questions rated on a Likert scale of 1 (definitely no) to 7 (definitely yes), and 3 open-ended questions for specific feedback about the program (Appendix A). Adverse events were assessed by the lead CEP during group exercise sessions as well as by asking participants to report any injuries related to participation in BEAUTY during home-based sessions.
Descriptive statistics were calculated for participant’s baseline demographics and physical/medical characteristics. Program attendance and program evaluation reports at the 12-week time point are also described. A χ2 or independent t test compared participants who had baseline and 12-week data and those who had data at only 1 time point. Main analyses included paired t tests comparing baseline to 12-week data for physical and psychosocial outcomes. Statistical analyses were performed using IBM SPSS Statistics (IBM Corp, Released 2011; IBM SPSS Statistics for Windows, version 20.0; IBM Corp, Armonk, New York).
A total of 100 breast cancer survivors participated in BEAUTY between August 2011 and July 2013. Of these, 96 (96%) consented to participate in the research component. Of the 96 women who started the program, 80 (83%) completed the 12-week assessment. The majority of reasons for not completing 12-week assessments were medical and lost communication. The Figure provides a flow diagram for the study.
Table 1 presents baseline demographic and medical characteristics for all participants who completed an initial assessment (N = 96). Differences in participants who had baseline and 12-week data, versus those who had data at only 1 time point for demographic and medical characteristics, were not significant (P > .05). Participants’ ages ranged from 24 to 73 years, with the majority (87.5%) between 40 and 70 years old. Most participants had a yearly annual household income of $80 000 or more (79.6%), were married (84.4%), were not working at the time of their baseline assessment (56.3%), and were diagnosed with stage II breast cancer (53.8%). At the initial assessment, participants were asked “Are you currently physically active?” and 84.4% answered yes.
From baseline to 12 weeks, resting heart rate increased (t79 = −3.27, P = .002), and body mass index (BMI) increased (t79 = −3.99, P = .000). All other physiologic outcomes (blood pressure, waist circumference, waist-to-hip ratio, skin folds, grip strength, and sit-and-reach and aerobic fitness) were maintained from baseline to 12 weeks (P > .05) (Table 2).
Scores on the FACT-B social well-being subscale showed a statistically significant decrease (t77 = 3.83, P = .000), and scores on the emotional well-being subscale increased (t77 = −2.15, P = .034) from baseline to 12 weeks; however, neither change reached clinical significance.38 No other FACT-B scores showed a statistical or clinical change from baseline to 12 weeks. Scores on the FACT–General (FACT-G), FACT-Cog, FACIT-Fatigue subscale, and the CES-D did not change from baseline to 12 weeks. All psychosocial outcome means and t test results are shown in Table 3.
Participant Attendance, Evaluation, and Injuries or Adverse Events
Participants attended an average of 7.5 (SD, 6.5) classes over 12 weeks (range, 0–24), of a possible 24 classes (2 classes per week available for 12 weeks). Almost a quarter of participants, 24.4%, attended at least 12 sessions, equivalent to the once-per-week suggestion for the program. Participant feedback about their experience after 12 weeks in the BEAUTY program was generally very positive. Most indicated (responded “yes,” “likely yes,” or “definitely yes”) that they enjoyed the BEAUTY program (96.2%), looked forward to attending exercise sessions (89.8%), felt the staff and group environment provided a sense of community (89.6%), and found the education sessions useful (94.5%). At 12 weeks, participants also reported (responded “yes,” “likely yes,” or “definitely yes”) that they felt stronger (78.2%), they could better perform daily activities (85.9%), and that attending the BEAUTY program was not an added stressor during their treatment (87.3%). There were no exercise-related injuries or adverse events that affected program attendance or completion.
This study evaluated the initial 12 weeks of BEAUTY, a community-based exercise program for breast cancer survivors currently on or within 3 months of chemotherapy or radiation treatment. Participants in this program were representative of breast cancer survivors in Canada,39 and results indicate that this program was safe, enjoyable, and effective in counteracting the usual declines in physical and psychosocial outcomes breast cancer patients experience during treatment.
Most physiologic outcomes, including body composition, muscular strength, aerobic fitness, and flexibility, were maintained during the 12-week program. Maintenance of muscular strength, aerobic fitness, and body composition is important, as women undergoing treatment for breast cancer often experience declines in lean body mass and muscle strength and increase in fat mass and body weight.40 Two physiologic measures showed statistical changes from baseline to 12 weeks. Resting heart rate showed a slight increase from the baseline to 12-week assessment and may be related to the tachycardic effects associated with certain chemotherapy drugs.41 The growing awareness of the potential cardiotoxic implications of many treatments for breast cancer (ie, anthracyclines) will be important to further consider within exercise testing and prescription for this population.
Body mass index increased from baseline to 12 weeks, reflective of the common problem of weight gain and unfavorable changes in body composition among women receiving adjuvant chemotherapy.42,43 Although the increase in BMI was statistically significant, this change (+0.47 kg/m2) actually represents only a very small weight gain. For a woman who is 5 ft 4 in tall, a 2.27-kg (5-lb) weight gain would result in approximately 1.0-kg/m2 change in BMI. We consider the minimal increase in BMI in this study a success, as women treated for breast cancer have an average weight gain of 4.5 kg, with most weight being gained during active treatment.44
In general, psychosocial outcomes including overall HRQL, cognitive function, fatigue, and depressive symptoms were maintained from baseline to the 12-week assessment. Scores on the FACT-B social well-being subscale showed a statistically significant decrease (ie, lower reported social well-being), whereas scores on the emotional well-being subscale increased (ie, enhanced emotional well-being) from baseline to 12 weeks. However, no changes in scores on the FACT-B, FACT-G, or any subscale reached clinical significance.45 Similar to the physiologic measures, maintenance of these outcomes is promising, as a previous randomized controlled trial for breast cancer patients who were currently receiving chemotherapy and/or radiotherapy found that all scores on the FACT-G and FACT-B decreased (ie, worsened) in the control group, and those who were allocated to the exercise group showed no differences in FACT-B scores.46 One other community exercise program for cancer survivors has measured changes in HRQL using the FACT-G, finding an increase of 4.8 points from baseline (mean, 81.2) to 12 weeks (mean, 86).20 However, this study did not differentiate between participants who were currently undergoing treatment and those who were not.
In the current study, there were no statistically significant differences in FACT-Cog subscale scores, but the score for “perceived cognitive impairments” did decrease (ie, showed improvement) from baseline to 12 weeks by −2.4 points (effect size d = 0.37), which is similar to a randomized controlled trial in breast cancer survivors on hormone therapy (effect size d = 0.35).47
There was no change in fatigue scores from baseline to 12 weeks, measured by the FACIT-Fatigue. Average fatigue scores in this study were lower (ie, worse fatigue) compared with a previous study in cancer patients who had not had chemotherapy or radiation therapy within the previous 6 months.34 This indicates the negative effects that chemotherapy and radiation treatment may have had on fatigue for the participants in this study and highlights the success of this program in maintaining fatigue levels during treatment. Maintenance of fatigue scores on the FACIT-Fatigue is also consistent with the results of a recent meta-analysis that examined the effects of aerobic exercise on fatigue in breast cancer patients on chemotherapy.48
There was no change in depressive symptoms from baseline to 12 weeks, and depressive symptoms did not reach clinical levels of depression (≥16) at either time point. Previous studies indicate that detecting a significant effect of exercise on depression may be more likely in breast cancer patients who have baseline scores on the CES-D that reach clinical levels of depressive symptoms.49
The BEAUTY program had high rates of completion for the 12-week assessment (83%), which is similar to some other community exercise program for cancer survivors,17,19 but higher than another program reported by Cheifetz et al,20 who saw 56.5% of participants completed 12-week assessments. Participant attendance at group exercise classes was lower (24.4% attended the suggested 1 class per week) than other similar community programs for cancer survivors who had completed treatment, which reported attendance rates of 88% at all sessions,19 and 88% attended more than half of sessions.17 Time demands and adverse effects due to treatment may have been factors in the lower participation rates seen in the current program. In addition, attendance at group exercise classes was not required as participants were provided with the option of home-based exercise. Distance from the participants’ home to the class location is also hypothesized to be a contributing factor to class attendance. Those who attended more than 12 of 24 classes (≥50%) lived an average of 12.3 km away, and those who attended less than 12 classes lived an average of 32.8 km away. Although differences in outcomes between those attending less than 12 sessions or more than 12 sessions were not significant, these preliminary findings indicate the need to address this barrier by providing more community location options or using technology to provide additional home-based support.
The absence of injuries and no reports of worsening lymphedema support the safety of this type of program for breast cancer survivors during treatment. The majority of participants were greatly pleased with the program and did not perceive it as an added stressor during treatment. The most frequent recommendations for improving the program included additional location(s) in other areas of the city and a longer duration of the program, which was implemented in year 2 when a 12-week maintenance phase was added. The maintenance program follows a similar structure to the initial 12-week program, with an increased focus on becoming an independent exerciser, and provides participants with a 24-week fitness assessment.
Strengths and Limitations
Strengths of the BEAUTY program are that it is a community-based program that targets breast cancer survivors during or within 3 months of completing treatment. Most other community programs for cancer survivors include participants who are years past diagnosis. Providing a free, ongoing exercise program for breast cancer survivors during treatment is a valuable resource to help manage symptoms and adverse effects of chemotherapy and radiation, including fatigue, negative changes in body composition, and declines in physical function, mental health, and HRQL.4,40,43,50,51 Targeting exercise adoption and adherence, BEAUTY may be capitalizing on the “teachable moment” following a cancer diagnosis in which women may be more responsive to making positive health behavior changes.21,22 BEAUTY was implemented in a university setting with access to exercise professionals who had breast cancer–specific training and experience. Each exercise program was individualized for each participant, and the presence of a CEP at group exercise sessions to provide modification and correct technique increased the safety and individual specificity of the program. Another strength of this program was its inclusion of only women undergoing treatment for breast cancer. Consistent with previous literature,52 many women valued the peer support of the group and perceived their relationship with others in program and the support they provided each other as one of the greatest benefits of the program, making it easier to get through the challenges of chemotherapy and radiation treatment.
One limitation of this program was that it was offered at only 1 location. Other programs for cancer survivors implemented at multiple locations have shown great success,17 and therefore future direction for the BEAUTY program includes expansion via community partnerships including the YMCA. Second, although participants were asked to record their exercise done at home, these logs were not returned consistently enough to analyze adherence to the recommended exercise prescription of 2 days per week of aerobic exercise and 1 day per week of resistance exercise. As part of the ongoing improvement of this program, we plan to increase prompting for participants to fill out and return these logs and have the exercise physiologist collect these logs each week; either at the exercise class or mailed, scanned, or faxed in by participants who do not attend class. Third, because this program was not a research-based intervention or randomized controlled trial, it did not have a nonactive control group for comparison. However, because this program was not limited by the rigor of a randomized control trial, it was able to be more inclusive of participants (only 2 women were deemed ineligible for this study because of medical complications), increasing the generalizability and thus the potential practical implications of our results. Fourth, this program used convenience sampling and may have preferentially recruited those who are motivated to participate in an exercise program. The majority of participants in this program reported being active prior to initiating the program, and perhaps greater efforts need to be made to recruit women who are sedentary prior to and at the time of their breast cancer diagnosis. Last, the demographic characteristics of participants in this program were consistent with other exercise programs for breast cancer survivors17,19; however, this sample was fairly homogenous, and therefore the results of this program can be generalized only to breast cancer survivors living in a large, metropolitan city, who are middle-aged, with a relatively high socioeconomic status. This suggests that recruitment strategies are needed to include underrepresented populations of breast cancer survivors including young, low-income/socioeconomic status individuals, ethnic minorities, and those who reside in rural locations.
Implications, Future Directions, and Conclusions
The findings from this study contribute to the need for and importance of exercise as part of treatment and care for breast cancer. Several published randomized controlled trials and interventions indicate that exercise is safe and efficacious during and following chemotherapy and radiation for breast cancer.4,8,9,14 This study found that a community exercise program for women undergoing treatment for breast cancer is feasible and effective in preventing declines in physical and psychosocial outcomes. Implications for nursing practice are the need for (1) increased clinician knowledge of the benefits and feasibility of exercise for breast cancer patients, (2) greater availability and awareness of cancer-specific exercise programs by nurses and other clinicians, and (3) an established system or process for referral of breast cancer patients from nurses to the appropriate exercise professional and/or program. The next step for BEAUTY is evaluation of the 12-week maintenance program. This evaluation will contribute information about the effectiveness of the full 24-week program on physiologic and psychosocial outcomes, as well as the capacity for BEAUTY to promote longer-term adherence and behavior change. Future goals include increasing sustainability and expansion of the BEAUTY program. Dissemination of the BEAUTY program in a range of capacities to a variety of user groups and potential delivery partners (eg, cancer care centers, fitness facilities, breast cancer organizations) is underway and supported by 2 grants from the Canadian Breast Cancer Foundation–Prairies /NWT Region.53,54 Establishing community partnerships to expand the BEAUTY program is also ongoing and will increase accessibility to the program.
The benefits of exercise for breast cancer survivors are well known; however, accessibility to programs for women during chemotherapy and radiation treatment is limited. BEAUTY fulfills this need, providing an example of an individualized, safe, and effective community exercise program for women undergoing treatments for breast cancer. Based on our findings, we believe this model of an evidence-based community program to maintain physical and psychosocial well-being of women living with breast cancer while on treatment is a promising step toward the integration of exercise into standard care for breast cancer.
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